Quality Account

Transcription

1 Quality Account

2 Contents Page Part 1 Contents Page Statement on Quality from the Chief Executive and Chairman 3 Statement on Quality from the Medical Director and Director of Nursing 4 Introduction 5 Part 2 Contents Page Priorities for Improvement Patient Experience 7 Patient Safety 8 Clinical Effectiveness 9 Statements from the Board 10 Geographical Area & Population 10 Our Services 11 Participation in National Audit 12 Local Trust Audit 12 Learning From Audit 13 Clinical Performance Indicators 14 Participation in Research 15 Goals agreed with Commissioners - CQUIN 17 What others say about us 18 Data Quality 19 Performance against Key Quality Indicators 20 What our Staff Say 22 Workforce and Organisational Development 24 Part 3 Content Page Performance against priorities Patient Safety 30 Medication Errors 32 Infection Prevention & Control 32 Safeguarding 33 Serious Incidents 34 NHS NHS 111 Patient Safety and Experience 36 Complaints and Contacts 37 Annex 1: Statement from the Lead Commissioning Group 39 Annex 2: Statement from the Council of Governors 40 Annex 3: Local Healthwatch and Overview & Scrutiny Committees 41 Annex 4: Statement of Directors responsibilities 51 Annex 5: External Audit Limited Assurance report 52 Annex 6: Glossary of Terms 55 Further Information 56 Appendix Divisional Profiles 57 2

3 Part 1 - Statement on Quality from the Chief Executivee and Chairman We are pleased to presentt the West t Midlands Ambulance Service NHS Foundation Trust ss Quality Report which reviews and sets out our priorities for We pride ourselves on the quality of care that patients receive fromm our service, and quality remains at the forefront of everything we do. Wee provide a high quality and responsive service, however we are not complacement and a we recognise that there is always more that we can do. At the end of each financial year, it iss always appropriate to look back and reflect on the past 12 months. This quality account demonstrates the qualityy of care patients received from our service and detailss those areas wheree improvements need to be made has been a very busy andd challenging year, with demand on services increasing. This puts additional pressure on staff who continue c too deliver excellent care to our patients, and we would like to commend our staff s for their continued hard work and commitment. During the year we have seen an increase in front-line staff, and a significant investment in new vehicles and equipment. The clinical outcomess we achieve are amongst the best in the country, andd we are committed to maintain or improve this position year on year. We are continuing to work with commissioners and stakeholders to make improvements across the wider health economy. We are active members of local System Resilience Groups that bring commissioners and providers together to make improvements to the urgentt care services. To the best of my knowledge the information contained in this reportt is an accurate account. Dr Anthony C. Marsh QAM SBStJ DSci (Hon) MBA MSc FASI Chief Executive Officer Sir Graham Meldrum CBE OStJ Chair 3

4 Statement on Quality from the Medical Director and Director of Nursing, Quality & Clinical Commissioning Ambulance services are being used by more and more people ass the pointt of first contactt with the NHS. People, often when they are mostt vulnerable call us for help, and it is our responsibility to make sure that we provide a service that meets the need of the person. Increasingly, people call our servicee for healthcare needs that aree not traditionally those provided by an emergency service and our challenge is to ensure that we are able to respond to such calls in a wayy that is proportionate to the person s need. We are a significant provider within thee health economy, and a it is important that our servicee continues to develop to make sure we provide the best service, based on people s needs and ensuring the bestt possible outcome from the resource we use. Ambulance services do nott work in isolation; we are part of a large health and social care system, and we can only provide exceptional services if all parts of the system work together. Patient experience does not happen in isolation, and good clinical outcomes are only achieved if everybody strivess for excellence. We are aware that we need to change how we work, and we are this year embarking on a new system of electronic recordd keeping that will enable us too view the primary care records of patients, enabling us to view the primary care record so that we can ensuree that patients receivee the most t appropriate care and treatment. Where patients need to be taken to another healthcare facility we are able to ensure that they go to the right place, first time. Our staff are the greatest asset for delivering high quality care, and we are grateful to them for the efforts they put in to ensuring that the care received byy patients is of the highest standard. We are keen to support our staff in their professional development to ensure that our standards of care remain high. Dr Andy Carson Medical Director Mark Docherty, RN MSc BSc (HONS) Cert MHS Director of Nursing, Quality & Clinical Commissioning 4

5 Part 1 - Introduction We have a vision to deliverr the right patient care, in the right r place,, at the right time, throughh a skilled and committed workforce, in partnership with local health economies. Put simply, patients must be central to all that we do. This means a relentless focus on patient safety, experience and clinical outcomes. At West Midlands Ambulance Servicee NHS Foundation Trust T we place quality at the very centre of everything that we do. We work closely with partners in other emergency services, different sections of the NHS and community groups. These include General Practitioners, mental health workers, trade associations and local community groups. Together we ensure that the patients remain at the forefront of servicee provision through uncompromising focus on improving patient experience, safety and clinical quality. The Quality Account is a yearly report that highlights the Trust s progress against quality initiatives and improvements made over the previous year and looks forward f to prioritising our ambitions for the year ahead. We understand as a provider organisation thatt to continue to improve quality it is essential that our patients and staff are fully engaged with the quality agenda. We continue c too reinforcee these throughh our current values. Vision Delivering the right patient care, in the right place, at the right time, through a skilled and committed workforce, in partnership with local health economies Values Achieve Quality and Excellence Strategic Objectives Establish market Accurately assess position as an patient need and Emergency direct resources Healthcare appropriatelyy Provider Work in Partnership World Class Servicee Patientt Centered Dignityy and Respect for All Skilled Workforce Teamwork Effective Communication 5

6 Part 2 - Priorities for 2015/16 In deciding our quality priorities for we have again chosen to keep the overarching objectives of improving patient experience, patient safety and clinical quality. This ensures thatt our quality priorities are aligned withh both Trust and national objectives. In determiningg our priorities wee have taken account of recommendations from the Francis report as well as the new focus of the Care Quality Commission. We have liaisedd with patients, userss and communities with the guidingg principle no decision about me, without me. Most importantly we have assessed our progress during the year against last year s priorities (see page 26) and have agreed that there is still much to be done andd that we need to continue some of these priorities for the coming year. In order to develop our Quality Account we communicated with staff via our weekly brief inviting them to comment and suggest priorities for improvement. We arranged a meeting with our General Managers to review prioritiess and performance from the previous year and again request r recommendations from a Divisional perspective. The Trust organised 2 engagements events where wee invited Healthwatch and Health Overview and Scrutiny Committees to ask their opinions and views on the potential content of this year s Quality Account. This hass provided an opportunity to gain their views of quality and the priorities we should bee setting for the year ahead. Engagement with commissioners, stakeholders, staff, patients andd the public is on- going. Patient Experience Improved engagement withh Learning Disabled Service Users Working with Public Health England to reducee Health Inequalities Patient Safety Reduce the risk of harm fromm delays in ambulance attendance Publicise lessons learnt and good practice from incidents, claims and complaints Clinical Effectiveness Ensuring the care delivered on scene is timely and effectivee Continue to improve all clinical outcomes 6

7 Patient Experience Priority WHY WE HAVE CHOSEN THIS priority WHAT WE ARE TRYING TO IMPROVE WHAT SUCCESS WILL LOOK LIKE Patient Experience Improved engagement with Learning Disabled Service Users Working with Public Health England to reduce Health Inequalities (3 Year Project) We recognise the importance of ensuring we communicate effectively with Learning Disability Servicer Users, the Trust would now like to ensure that they undertake engagement events with this service user group to find out their experiences of the service, do we communicate effectively and all key communication documents are in an easy read format, expanding on the work recently undertaken by the Trust We know that "Health inequalities are preventable and there are unfair differences in health status between groups, populations or individuals. They exist because of unequal distributions of social, environmental and economic conditions within societies Communication with Learning Disability Users An understanding of Learning Disability Service Users Experiences with the Trust Is it a good/bad experience can lessons be learnt We are trying to improve equal access to services for all members of society regardless of their social, environmental or economic background A positive experience by Learning Disability Service Users To be able to meet expectations of service users To be able to communicate in an effective way Improve engagement for 3 key disadvantaged groups. How we will monitor progress: Reporting frameworks have been established for each priority to be assessed against performance on a monthly basis and progress reported to the Quality Governance Committee Responsible Lead: Consultant Paramedic (RC) and Head of Patient Experience, Senior HR Manager Date of completion: March

8 Patient Safety PRIORITY WHY WE HAVE CHOSEN THIS WHAT WE ARE TRYING TO WHAT SUCCESS WILL LOOK LIKE PRIORITY IMPROVE Reduce the risk of avoidable harm from delays in ambulance attendance. We recognise the importance of providing safe and timely care to ensure the best clinical outcomes for our patients. We aim to proactively ensure that the right resource is allocated to the right patient at the right time; first time without contributing to further harm to the patient. Reduction in incidents, claims and complaints that result in moderate harm or above as a result of delayed attendance. Increased learning from audit of delays resulting in harm. PATIENT SAFETY Publicise lessons learnt and good practice from incidents, claims and complaints. We want to demonstrate our commitment to being open and candid with both patients and staff when mistakes are made but also when achievements are realised. We aim to improve the way in which we share lessons we have learnt from investigations, complaints and claims with all of our stakeholders to ensure we are able to demonstrate our candidness. Compliance with Statutory Duty of Candour Monthly Patient Safety Bulletin Monthly published information on web site How we will monitor progress: Reporting frameworks have been established for each priority to be assessed against performance on a monthly basis and progress reported to both the Learning and Clinical review Group. Responsible Lead: Head of Patient Safety Date of completion: March

9 Clinical Effectiveness Priority WHY WE HAVE CHOSEN THIS PRIORITY WHAT WE ARE TRYING TO IMPROVE WHAT SUCCESS WILL LOOK LIKE CLINICAL OUTCOMES Ensuring the care delivered on scene is timely and effective Continue to improve all clinical outcomes With the pressure on the Hospital Emergency Departments there is a drive to deliver appropriate care to patients who call 999 which may not require transfer to ED. We want to be sure that the care we give is the right care first time using NHS resources safely and effectively. We have a number of Clinical Performance measurements that provide us with an indication that treatment given is appropriate and effective. We have decided that all of these are equally important to our patient care. Transfer decisions are made quickly. Time on scene is reduced where appropriate. All Ambulance Clinical Performance measurements will improve based on 2014/15 data Patients requiring immediate transfer are taken to hospital quicker. Care delivered on scene including referrals to other agencies is safe and results in a positive patient experience. Patients receive high quality care. How we will monitor progress: Reporting frameworks are well established for each priority to be assessed against performance on a monthly basis. Progress is, and will, continue to be monitored within the Trust Committees and to our Commissioners. Reports will be sent to the Trust Board of Directors and these will be published on our website. Responsible Director: Director of Nursing, Quality & Clinical Commissioning Date for Completion: March

10 Statements from the Board During 2014/15 West Midlands Ambulance Service provided NHS services as above. The Trust sub-contracted to 2 Voluntary Urgent Care Providers. WMAS provides Patient Transportation Services to other NHS Trusts. To ensure excellent business continuity during times of surges in demand or in support of major incidents, the Trust has the facility to call upon a small number of Ambulance Subcontractors to supplement service delivery. Sub-contractors are subjected to a robust governance review before they are utilised. The Board of Directors has strong governance arrangements in place that have been embedded over a number of years, the Board of Directors has reviewed all of the data available and is assured that this account is an accurate account on the quality of care in all of these services. The total service income received in 2014/15 from NHS sources represents 98% of the total service income for the Trust. More detail relating to the financial position of the Trust is available in the Trust s 2014/15 Annual Report. Geographical Area & Population The Trust serves a population of 5.6 million who live in Shropshire, Herefordshire, Worcestershire, Coventry and Warwickshire, Staffordshire and the Birmingham and Black Country conurbation. The West Midlands sits at the Heart of England, covering an area of over 5,000 square miles, over 80% of which is rural landscape. The West Midlands is an area of contrasts and diversity. It includes the second largest urban area in the country, covering Birmingham, Solihull and the Black Country where in the region of 45% of the population live. The Region is also well known for some of the most remote and beautiful countryside in the Country including the Welsh Marches on the Shropshire / Welsh borders and the Staffordshire Moorlands. 10

11 Our Services West Midlands Ambulance Service became a NHS Foundation Trust on 1 st January The Trust has a budget of approximately 215 million per annum. It employs over 4,000 staff and operates from 15 Operational Hubs and over 100 Community Ambulance Stations together with other bases across the Region. In total the Trust utilises over 800 vehicles including Ambulances, Response Cars, Non-Emergency Ambulances and Specialist Resources such as Motorbikes and Helicopters. The Trust is supported by a network of Volunteers. More than 800 people from all walks of life give up their time to be Community First Responders (CFRs). CFRs are always backed up by the Ambulance Service but there is no doubt that their early intervention has saved the lives of many people in our communities. WMAS is also assisted by Voluntary organisations such as the British Red Cross, St. John Ambulance, BASICS doctors, water-based Rescue Teams and 4x4 organisations. During West Midlands Ambulance Services Foundation Trust provided 5 core services: 1. Emergency and Urgent: This is perhaps the best known part of the Trust and deals with the 999 calls. Initially, one of the two Emergency Operations Centres (EOC) answers and assesses the 999 call. Emergency Operations Centres deal with approximately 76, calls each month, over 95% of which are answered within 5 seconds. Each 999 call is triaged through NHS Pathways in order to ensure that the correct categorisation is reached to meet the needs of the patient. 2. Patient Transport Services (PTS): A large part of the organisation deals with the transfer and transport of patients for reasons such as hospital appointments, transfers between care sites, routine admissions and discharges and transport for continuing treatments such as renal dialysis. The Trust completed approximately 640,000 PTS patient journeys during 2014/ Emergency Preparedness: This is a small but important section of the organisation which deals with the Trust s planning and response to significant incidents within the Region as well as co-ordinating a response to large gatherings such as football matches and festivals. It also aligns all the Trust s Specialist assets and Operations into a single structure. 4. Make Ready is a dedicated ambulance preparation system operating successfully in most of the Trust that was implemented during Under the Make Ready system, specialist non clinical staff clean, prepare and stock the ambulances ready for the start of each shift. 5. NHS 111 Service which covers Birmingham, Solihull, the Black Country, Shropshire, Herefordshire, Coventry and Warwickshire. The service has more than received 940,000 calls in the previous 12 months. 11

12 Participation in National Audit WMAS recognises as a Foundation Trust the importance of ongoing evaluation of the quality of care provided against key indicators. As a member of the National Ambulance Service Clinical Quality Group (which develops National Clinical Performance Indicators and National Clinical Audits), we actively partake in both national and local audits to identify improvement opportunities. As a result, the Trust has a comprehensive Clinical Audit Programme which is monitored via Clinical Audit & Research Programme Group. The Trust has participated in 100% of national audits and zero of national enquiries. The Trust submits data to the Department of Health Ambulance Quality Indicators and to the National Co-coordinator for Clinical Performance Indicators. National Audits Audit WMASFT Eligible WMASFT Participation National Non Conveyance Audit (NANA) 100% Ambulance Quality Indicators (Clinical) 100% Clinical Performance Indicators 100% Myocardial Infarction National Audit Programme (MINAP) 100% Number of Cases Submitted The final AQI results are dependent on external information and will be available and published by the Trust in June Local Trust Audit In addition to these submissions, the Trust produces Local Performance indicators to enable local areas to implement improvements. The Trust is committed to developing links with Local Hospitals to access patient outcomes for patients in prehospital cardiac arrest. Local Audit Trust Local Clinical Audits 1. Management of Mental Health 2. Deliberate Self Harm 3. Patients Discharged at Scene 4. Feverish Illness in Children 5. Management of Head Injury 6. Management of Asthma 7. Management of Peri Arrests 8. Management of Obstetric Emergencies 9. Clinical Records Documentation 10. Appropriateness of Medicines Management 11. Management of Acute Coronary Syndrome Audit 12. Management of Pediatric Pain 13. Paediatric Medicine Management 14. Paediatric Patients Discharged at Scene 15. Hear and Treat 12

13 Learning from Audit During the Trust undertook the third clinical audit to measure the quality of the documented assessment and management of patients with Acute Coronary Syndrome. Acute Coronary Syndrome describes a number of conditions affecting the Heart, these include: Angina Unstable Angina ST Elevation Myocardial Infarction Non ST Elevation Myocardial Infarction Heart Failure Sudden Cardiac Death The Ambulance Service has a significant role in the assessment and management of Acute Coronary Syndrome, the appropriate assessment and management can significantly reduce mortality and morbidity. Following the previous clinical audit improvement plan, which included a 2 year training plan, there was an increase in the following. Documentation of key timings i.e. onset of the symptom, time of ECG Assessment of the patient s pain Oxygen administration The following recommendations were made to continue improvement: Communication to staff to explain the rationale for key treatments Review of the on line educational pack Work with local managers to develop local strategies Develop clinical guidelines for the management of ACS patients. Management of Paediatric Pain This was the first clinical audit the Trust has undertaken to examine the management of paediatric pain in the pre-hospital environment. Controlling pain is essential in order for the ambulance practitioner to be able to assess the patient. Children have differing needs to the adult patient. Their ability to understand and cope with pain varies greatly with age. The key area of concerns the clinical audit highlighted for the management of paediatric pain surrounded the assessment and documentation of pain, the administration of analgesia and that the administration is as per guidelines. The improvement plan that was identified following this clinical audit was: Inclusion of Paediatric pain management within training for 2015/16 Review the online educational pack on VLE Develop a reference guide for staff relating to the assessment and management of pain in the paediatric patient. Communication to staff regarding the results of the clinical audit. 13

14 Clinical Performance Indicators The Trust takes part in the National Clinical Performance Indicators which look at the following conditions: Asthma Over 5 million people in the UK have asthma and there are almost 4 million consultations and 74,000 hospital admissions for asthma each year in the UK. Asthma sufferers are prone to an over-sensitive immune system and an asthma attack can be precipitated by a number of things, which are known as triggers. A trigger is anything that irritates the airways and causes the symptoms of asthma to appear. On average, 4 people per day or 1 person every 6 hours dies from asthma. It is estimated that approximately 90% of asthma deaths could have been prevented if the patient, carer or health care professional had acted differently. Trauma Care Single limb fracture Extremity fractures are commonly seen in pre-hospital care. They demonstrate a wide variety of injury patterns which depend on the patient s age, mechanism of injury, and pre-morbid pathology. Febrile Convulsion A febrile convulsion is a seizure associated with fever occurring in a young child. Most occur between 6 months and 5 years of age, and onset is rare after 6 years of age. Febrile seizures arise most commonly from infection or inflammation outside the central nervous system in a child who is otherwise neurologically normal. Seizures arising from fever due to infection in the central nervous system (e.g. meningitis and encephalitis) are not included in the definition of febrile seizure. Fever is usually defined as having a temperature of more than 37.5 C. Elderly Falls (Pilot) Falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year. Falls are associated with increased morbidity, mortality, and nursing home placement. The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falling also affects the family members and carers of people who fall. Falls are estimated to cost the NHS more than 2.3 billion per year. Therefore falling has an impact on quality of life, health and healthcare costs. These patients are at potential risk of major trauma as there is evidence of the impact of falls <2m on traumatic head injuries and undiagnosed subdural haemorrhages. These patients may re-contact the service following a fall, which would indicate that leaving patients safely at home has not been achieved. Care Bundle Performance Asthma Trauma Single Limb Febrile Convulsion Elderly Falls The CPI run 3 months behind for submission to the national group and so actual won t be ready for submission until June. 14

15 Participation in Research A key focus for the National Institute for Health Research is the development and delivery of quality, relevant, patient focused research within the NHS. WMASFT continues to be committed to supporting research within pre-hospital care, thus providing evidence to support improved patient care, treatment and outcomes. To achieve this we work with Universities within the West Midlands and further afield as well as acute hospitals, pharmaceutical companies etc. We also work with the Clinical Research Network West Midlands to ensure all research we take part in complies with the Research Governance Framework thus safeguarding participants in research. During WMAS has supported several portfolio studies 1 the number of patients receiving relevant health services provided or sub-contracted by WMAS in that were recruited during that period to participate in research approved by a research ethics committee was number of recruits and graph showing all ambulance trusts to be added when available in May. Highlights of some research studies which took place during Warwick Spinal Immobiliser A new spinal immobilisation device has been designed at Warwick University which aims to determine if the new device is more effective than the existing devises used to immobilise patients with suspected spinal/neck injuries. If effective this device will remove the need to apply cervical collars, thereby reducing patient anxiety/ claustrophobia. Paramedics took part in assessing the new working prototype device on healthy volunteers. Work now continues at Warwick University to further develop the device. Out of Hospital Cardiac Arrest (OHCA) Run by Warwick University and funded by the Resuscitation Council (UK) & British Heart Foundation, this project will try to establish the reasons behind such big differences nationally in outcome from Cardiac Arrest. It will develop a standardised approach to collecting information about OHCA and for finding out if a resuscitation attempt was successful. The project will use statistics to explain the reasons why survival rates vary between regions. It will provide feedback to ambulance services to allow ambulance services to learn from one another and promote better outcomes for patients. Brain Biomarkers after Trauma Traumatic Brain Injury is a major cause of illness, disability and death and disproportionally affects otherwise young and healthy individuals. Biomarkers are any characteristic which may be used to gain insight into the person either when normal or following injury or disease. The study will look at biomarkers taken from blood, from fluid in the brain tissue and from new types of brain scans and investigate whether any biomarkers can give us insight into novel therapeutic strategies. WMAS and Midlands Air Ambulance are working with University of Birmingham to support this study. 1 The National Institute for Health Research (NIHR) portfolio comprises clinical research studies of high quality and clear value to the NHS. 15

16 The Development of a Parental Suicide Bereavement Training Pack The aim of this study was to develop a training pack for health professionals to support them in dealing with a parent bereaved by suicide. Paramedics took part in interviews which focused on their perception of caring for a patient who has attempted suicide and subsequently died; the perceived implications when dealing with and informing parents bereaved by suicide; the paramedics perceived needs when caring for those bereaved by suicide and their views of what guidance they would require in a parental suicide bereavement training package. Results from 2 studies which the trust have previously taken part in Prehospital Assessment of a mechanical compression device - The aim of this trial was to evaluate the effect of using a LUCAS 2 device rather than manual chest compressions during resuscitation by ambulance clinicians after out of hospital cardiac arrest. The LUCAS 2 device undertakes chest compressions on patients whose heart has stopped i.e. have had a Cardiac Arrest. The trial aimed to show whether use of such a device improved outcome for patients over manual compressions performed by a paramedic. We took part in this study run by Warwick Clinical Trials Unit (Warwick University) in conjunction with 3 other ambulance trusts. Out of the 4471 patients included in the trial WMAS recruited 2723 (61%). The results were published in the Lancet in November 2014 with the conclusion that the introduction of LUCAS-2 did not improve the primary outcome of survival to 30 days. These results will now be reviewed by relevant national and international bodies leading to guidance for NHS Trusts on the use of mechanical compression devises. ATLANTIC This was an international, randomized, parallel-group, double-blind, placebo controlled phase IV study by AstraZeneca. The trial looked at whether giving a drug called Ticagrelor (normally given in hospital) to patients suffering a heart attack was more effective if given earlier i.e. in the ambulance. We took part in this study in collaboration with University Hospitals Coventry and Warwick. The global recruitment target of 1,870 patients we met, 14 of which were recruited by WMAS paramedics. Results were published in The New England Journal of Medicine in Sept 2014 and showed that Prehospital administration of Ticagrelor in patients with acute STEMI (type of heart attack) appeared to be safe but did not improve pre-pci coronary reperfusion. 16

17 Goals Agreed with Commissioners CQUIN Indicators Indicator Name Indicator Weighting (% of CQUIN scheme available) Expected Financial Value of Indicator Achieved 1. Friends and Family Test Implementation of staff FFT NHS , % Trusts Only Friends and Family Test Early Implementation , % Friends and Family Test Phased expansion , % 2. Hear and Treat CPGMs (2 Year) , % 3. Timely Facilitation of EPR system , % 4. Pre Alert hyper acute stroke pathway , % 5. Learning from Safeguarding Concerns , % 6. See and Treat CPGMs (2 Year) , % Total % 4,178, % Commissioning for Quality and Innovation (CQUIN) is a payment framework that enables commissioners to agree payments to NHS providers based on agreed quality and innovation work. A proportion of WMAS income during was based on achievement of quality improvement and innovation as detailed in the CQUIN framework to ensure positive outcomes result in an improved quality of service. 1. This CQUIN is a national requirement to promote and improve feedback from patient s regarding their experience with WMASFT. 2. This CQUIN is designed to identify regional DOS gaps in Primary Care service provision by conducting an analysis of all Hear & Treat re-contacts made to the Trust. 3. This CQUIN is designed to promote and support the timely implementation of the Electronic Patient Record (EPR) system within the Trust, which will result in numerous quality improvements to the service. 4. "A pathway is in place between WMASFT and the receiving Hyper-Acute Stroke Unit (HASU), in line with the Midlands and East Stroke service specification The Ambulance Paramedic service links with the receiving hospital when they have a suspected stroke patient, providing a system of pre-alert to enable potential stroke patients (FAST positive) to be met on arrival. 5. There is a need to ensure safeguarding practices support the needs of vulnerable children and adults. Therefore this indicator is aimed at ensuring that providers continue to embed safeguarding into practice, implement lessons learnt following a safeguarding event, reflect on practice and ensure that the voice of the child/adult is heard. 6. This CQUIN is designed to identify regional DOS gaps in Primary Care service provision by conducting an analysis of all See & Treat re-contacts made to the Trust. 17

18 What Others Say About Us The Trust has been registered with the CQC without conditions c since This includes compliance with the t Healthh and Social Care Act A 2008 and Hygiene code (HC2008). The Care Quality Commission hass not taken enforcement action against West Midlands Ambulance Service during 2014/15. During January 2014,, the CQC carried out a review of the servicee that included; inspections of premises and ambulances, interviews with patients, staff and managers, feedback from partner organisations and local authority scrutiny and safeguardingg committees and review of all our compliance with other regulatory bodies. The final report available from or the Trust website confirms the Trust remains compliant with all the requirements of registration except for a minor failure in Outcome 4 - 'Care & Welfare of people who use our Service'. The CQC determined the Trust was required to provide a short term plan for improvements in operational performance targets t Thank you! as some patients, whilst receiving excellent treatment On Sunday 8th February 13:30 I was unconscious my wife from staff, had experienced dialled 999. The Ladyy answering g the call, stayed on the delays in response times. The phone reassuring myy wife until the Paramedics arrived; Trust agreed a plan to improve THANK YOUU response times by July 2014 Two Paramedics arrived 13:45 ishh They weree re assuring which was achieved., they carried out all the tests required with Layman explanations, an anomaly on thee ECG required a second West Midlands Ambulance confirming the first, again re assurinshould s have further investigation at Uses Service for inclusion in the Russell ss Hall I agreed. They delivered me to t the ECG they then Servicee did not submit records during 2014/15 to the Secondary recommended that I Hospital Episode Statistics which room they came wishing me all the best. are included in the latest We hear so much criticism of our NHS I felt the other side published data. The Trust is not needed to be recorded. THANK YOU to the t two required to submit this data as it relates to admissions, outpatient appointments and A&E attendances in NHS Hospitals. 18

19 Data Quality West Midlands Ambulance Service takes the following actions to assure and improve data quality for the clinical indicators, the Clinical Audit Department completes the data collection and reports. The patient group is identified using standard queries based on both the paper Patient Report Forms and the Electronic Care System. These clinical records are then audited manually by the Clinical Audit Team using set guidance. The data is also clinically validated and then analysed following an office procedure that is available to the Clinical Audit Team and is held on the central Clinical & Quality network drive. The process is summarised as: For the clinical indicators, the Clinical Audit Team completes the data collection and reports. The Patient Report Forms/Electronic Care Summary records are audited manually by the Clinical Audit Team. A process for the completion of the indicators is held within the Clinical Audit Department on the central network drive. A Clinician then reviews the data collected by the Clinical Audit Team. The data is then analysed and reports generated following a standard office procedure. A second person within the Clinical Audit Team checks for any anomalies in the data. The results are checked against previous month s data checking for trends and consistency. The Clinical Indicators are reported through the Trust Clinical Performance Scorecard The reports are then shared via Quality Governance Committee to the Trust Board, Commissioners and Service Delivery meetings. NHS Number and general Medical Practice Code Validity The Trust did not submit records during 2014/15 to the Secondary Uses service for inclusion in the Hospital Episode Statistics to be included in the latest published data. Information Governance Toolkit Attainment Levels West Midlands Ambulance Service Information Governance Assessment Report overall score for 2014/2015 was 80% and was graded satisfactory Clinical Coding Error Rate West Midlands Ambulance Service was not subject to the Audit Commission s Payment by Results Clinical Coding Audit during 2014/

20 Performance against key quality indicators To ensure patients of the West Midlands receive quality care from their Ambulance Service a set of key Performance Indicators and Ambulance Quality Indicators have been set nationally. These help set our policies and guidelines and develop our organisational culture that places quality at the top of the Trust s agenda. The following details the figures for each CPI/AQI and highlights the national mean percentage and the position of WMAS against other Trusts. All Ambulance Trusts are required to report the following mandatory Quality Indicators: Red Ambulance Response Times Percentage of Category A telephone calls (Red 1 and Red 2 calls) resulting in an emergency response by the trust at the scene of the emergency within 8 minutes of receipt of that call during the reporting period. Percentage of Category A telephone calls resulting in an ambulance response by the trust at the scene of the emergency within 19 minutes of receipt of that call during the reporting period. Care of ST Elevation Myocardial Infarction Percentage of patients with a pre-existing diagnosis of suspected ST elevation myocardial infarction who received an appropriate care bundle from the trust during the reporting period. Care of Stroke Patients Percentage of patients with suspected stroke assessed face to face who received an appropriate care bundle from the trust during the reporting period. Ambulance Response Times WMAS WMAS National Target Highest Nationally Lowest Nationally Red 1 response within 8 minutes 77.5% 80.0% 75% 80.9% 67.2% Red 2 response within 8 minutes 74.3% 73.6% 75% 75.4% 59.7% Red 19 Min Performance 96.8% 97.0% 95% 96.8% 91.2% Green 2 90% 30mins 88.3% 88.6% 90% N/A N/A Green 4 90% triage in 60mins 99.4% 99.6% 90% N/A N/A Significant efforts were made to achieve all of the operational performance targets during 2014/15. We will continue to work with our Commissioners and other Providers such as Acute Hospital colleagues to ensure improvements in the provision of healthcare for the people of the West Midlands. WMAS continues to employ the highest Paramedic skill mix in the country with a Paramedic present in over 95% of crews every day. We are actively recruiting student and graduate Paramedics this year, which will further boost our capacity to respond and our clinical performance for patients. 20

21 STEMI (ST-elevation myocardial infarction) This is a type of heart attack. It is important that these patients receive: Care bundles have been developed to ensure patients get the best care based on current evidence. Care bundles include a collection of interventions that when applied together can help to improve the outcome for the patient. The STEMI Care Bundle requires each patient to receive each of the detailed interventions below. Aspirin - this is important as it can help reduce blood clots forming. GTN this is a drug that increases blood flow through the blood vessels within the heart. (Improving the oxygen supply to the heart muscle and also reducing pain). Pain scores so that we can assess whether the pain killers given have reduced the pain. Morphine a strong pain killer which would usually be the drug of choice for heart attack patients. Analgesia Sometimes if morphine cannot be given Entonox, a type of gas often given in childbirth, is used. Call to Balloon - 75% of patients that have Primary Percutaneous Coronary Intervention (PPCI) should do so within 150 minutes of the initial call. This treatment is provided at a specialist heart attack centre. The Care Bundle requires each patient to receive each of the above. The AQIs include measurements for the management of STEMI cases: Year-to-date Clinical Performance relating to STEMI and Stoke AQI s Mean (YTD) Ambulance Quality Indicators / Clinical Performance Indicators WMAS (13 14) WMAS (14 15) National Average Highest Lowest STEMI Care Bundle 75.28% 75.05% 80.50% 83.16% 69.57% Stroke Care Bundle 94.24% 93.73% 97.10% 95.58% 91.13% Stroke Care Bundle A stroke care bundle includes early recognition of onset of stroke symptoms and application of the care bundle to ensure timely transfer to a Specialist Stroke Centre. Clinical managers continue to improve work in this area by; Facilitating ASQUI workshops throughout the region Auditing cases where stroke may not have been diagnosed Ensuring the correct resource is sent to stroke patients 21

22 What our Staff Say? As in previous years, the National Staff Survey was conducted for WMAS by Quality Health. A total of 850 questionnaires were sent to randomly selected staff across the whole of the Trust. There were weekly reminders in the Weekly Briefing, together with reminder letters sent out by Quality Health to individuals to help the return rate. The Survey closed on the 1 st December The responses from staff are reported as 28 key findings and include the calculation of an overall staff engagement score. The staff engagement score incorporates staff s perceived ability to contribute to improvements at work, whether they would recommend the Trust as a place to work or receive treatment, and the extent to which they feel motivated and engaged in their work. The Trust s overall staff engagement score in 2014 was 3.30 out of 5, compared to 3.15 in The national average staff engagement score in the ambulance service trusts in 2014 was The key findings in which the Trust has shown the largest improvement are: Percentage of staff appraised in last 12 months (up 12%) Staff motivation at work (up from 3.3 to 3.51) Percentage of staff reporting errors, near misses or incidents witnessed in the last month (up 4%) The Trust achieved scores which placed it in the best 20% of ambulance service trusts in half of the 28 outcomes. However the areas where the Trust s performance is outside of this 20% are a clear indicator of where improvements need to be made. As part of the Trust s action plan, following the national staff survey for 2013, the Trust has developed an aligned bespoke survey to further delve into the findings. The full Survey results were published on the 26 th of February 2015 on the NHS Employers websitehttp:// Follow the link for a copy of the WMAS Summary Report for survey results Equality and Diversity is built into everything the Trust does including policies, practices and strategies, public engagement and consultation events, where the Trust regularly asks local communities how it can improve services and practices. Diversity in employment produces a workforce sensitive to the different needs of the community and the Trust has developed a vision for ensuring equality, diversity and inclusion, in both employment and service delivery which reflects `respect, dignity and fairness to all`. 22

23 The Trust has endorsed the Equality Delivery System (EDS), which is an NHS Equality and Diversity Framework, to assist in delivering better outcomes for patients and staff. We have been able to identify and consider further steps which will meet the needs of our staff and service users who share the relevant protected characteristic group. We have also published our Equality Data Analysis report 2014/2015 and will continue to publish our data with comprehensive analysis annually, in order to meet our Public Sector Equality Duty (Equality Act 2010). As demonstrated within the report, we will improve the way we make informed decisions about our policies and practices, which are based on evidence, and the impact of our activities on equality and the protected characteristic groups. For further information please follow the link Equality Data Analysis report 2014/

24 Workforce and Organisational Development Our People The Trust is making progress towards the achievement of 70% Paramedic skill mix. The Trust aims to achieve an average increase in Paramedic skill mix from 61% for 2013/2014 by increasing the number of Paramedics from an average of 1322 to 1657 i.e. 65% of Operational Staff by 2016/2017 and 1878 paramedics in 2017/18 representing 70%. The Trust has worked hard to avoid vacancies in key areas that can lead to operational difficulties and adverse patient outcomes. In order to achieve this, the Trust has reduced the average time from advert to appointment from 20 to 15 weeks. 2014/15 Appraisals Mandatory Training WMAS 43.26% 63.75% YTD* Programme running until September 2015 Staff Development 2014/15 Planned 2014/15 Trained Graduate Paramedic Recruitment Technician to Paramedic Conversion Student Paramedic L Student Paramedic L ECA to Tech 21 0 HCRT to Tech

25 Health and Wellbeing Working in partnership with Staff side the Trust continues to develop a Health and Wellbeing Strategy and action plan to ensure that health and well-being of staff is supported. Managers and staff are being supported to update and develop their skills. The Trust are supporting up to 50 Managers to complete an Engaging Leaders Programme of Management Development. The Trust wants to see a 5% improvement in staff recording that they feel valued and engaged in Staff survey results as well as assurance that there is an Increase in the number of staff with reviewed personal development plans. The Trust also wants evidence that staff are supported to receive the appropriate level of training as per the training plan. 25

26 Part 3 - Review of Performance against Priorities Patient Experience Priority Progress How we have done Successful implementation joint working/engagement with other NHS Trusts within the West Midlands area of the Friends and Family Test (FFT) NHS England released guidance on 21 July 2014 on the implementation of the Friends and Family Test (FFT) question for Ambulance Services. FFT was advertised and promoted through local press and radio but also through utilisation of social media. "How likely are you to recommend our service to friends and family if they needed similar care or treatment?" Engagement with stakeholders has been facilitated though: Posters displayed in Vehicles and GP Surgeries -Posters have been devised and will be placed in GP Surgeries and Emergency Departments advising how to make contact with the Patient Experience Team. There is also a QR code that patients can scan which will take them to the Survey page on the internet which features the FFT question. Healthwatch -The Patient Experience Team have liaised with Healthwatch advising of the implementation of the FFT question in Ambulance Services. Foundation Trust Members An article featured in the December addition of the newsletter. Staff - We have raised awareness of the importance of offering this question to patients through the Trust Weekly Brief. We capture FFT feedback via? Website -The FFT question features on the home page of the Trust website and allows people to complete and submit on line. Patient leaflet -The Trust has also devised a leaflet which can be returned to the freepost address. Work to date has been in advance of the national implementation of April 2015 and therefore there are no metrics published. Achieved 26

27 Priority Progress How we have done Addressing Health Inequalities (3 year project) During 2014/15 this priority established how we can support our Public Health Colleagues to improve the health of the homeless and travelling, and migrant communities. The focus during 2015/16 will be on making every contact with these groups count. Achieved Patient engagement focusing on the under 18s We have successfully engaged in variety of events targeted at under 18 s. The Patient Experience Team has been involved in 12 events across the region during this financial year. Organisation Development have also attend events awaiting confirmation of number. Example of the types of events attended: Gypsy Traveller Day 999 Fun days with other services Fire Service Open Day Careers Events School Visits Young Carers Event Lloyd the Paramedic Turtle all schools were asked to design a mascot for the Trust. Two young designers from Rugeley & Walsall area were successful in the creation of Lloyd who will attend future engagement events in the future. We have distributed 1745, junior paramedic packs following events with the local community including schools, cubs and scouts. We have received 62,743 hits on the new website since December There is a Junior paramedic ipad app available for download on the WMAS Commercial website along with published news articles. Achieved 27

28 Priority Progress How have we done Single limb fractures During 2014/15 we did not achieve significant improvements in this priority therefore we will be continuing the focus as part of the overall priority for improvements in Clinical Care. Not achieved Patient Safety Maintaining Neonate Temperatures Promoting skin to skin contact during transfer: As there was no product on the market that met both European Safety standards and the requirement of the ambulance service, WMAS worked with a company to develop a product that complies with European Safety standards and the requirement of the ambulance service. WMAS engaged with WMAS staff, Midwives and a mothers group to develop a harness device that encourages skin to skin transfer for mother and baby. This device is now on trial to consider the logistical elements of its use and is awaiting evaluation to determine implementation. Accurately measuring neonatal temperatures: New thermos scans have been sourced and purchased in order for the accurate temperature of new born babies can be achieved. Audit tools have been developed and agreed to monitor compliance with recording new born temperatures. Figures will be monitored via the audit and clinical review committees. Achieved General Pain Management During 2014/15 we did not achieve significant improvements in this priority therefore we will be continuing the focus as part of the overall priority for improvements in Clinical Care. Not achieved 28

29 Clinical Outcomes Priority Progress How have we done Timely and Effective Transfer Timely and Effective care delivered on scene - commissioning Timely and Effective Care on scene - clinical and training This priority was implemented in order to improve the response times between the first clinician on scene and the arrival of a double crewed ambulance able to transport our patient to hospital. There has been an improvement This priority identified the delays crews experienced when trying to access other services for patients in their own homes. We will continue to work with Commissioners and other Providers to identify gaps in services. The work done during 2014/15 identified areas for improvements, we will continue this work as part of the priorities for 2015/16 to ensure the service we provide to our patients is timely and effective. Partially Achieved Achieved Partially Achieved 29

30 Patient Safety Reporting, monitoring, actioning and learning from patient safety incidents is a key responsibility of any NHS provider. At WMASFT, we actively encourage all of our staff to report post patient safety and non-patient safety incidents so that we are able to learn when things go wrong. This helps us to recognise where improvements are required and make changes. - Combined Performance We encourage staff to report all incidents, near misses, issues and concerns, particularly where there has been no actual Harm. These present the Trust with the opportunity to learn lessons before a patient is actually harmed. This is important both to resolve the immediate issues that have been raised and to identify the wider themes and trends which need more planning to address. Analysis of all incidents takes place and is supported by triangulation with other information such as complaints, claims, coroners inquiries and safeguarding cases. These are discussed monthly at the Learning Review Group. The meeting is chaired by the Deputy Director of Nursing & Quality and attended by clinicians from across the organisation. Themes and trends are also reported quarterly to Clinical review Group, Quality Governance Committee and the Trust Board. A positive safety culture is indicated by high overall incident reporting with few serious incidents and we continue to work towards achieving this. Incidents: An incident is any unplanned event which has given rise to actual personal injury, patient dissatisfaction, property loss or damage, or damage to the financial standing or reputation of the Trust. Near Miss: Any occurrence, which does not result in injury, damage or loss, but had the potential to do so Issue/Concern: If it does not fit into any of the above definitions 30

31 Total Number of Patient Safety Incidents reported by month Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Total Birmingham Black Country Coventry & Warwickshire West Mercia Staffordshire PTS EOC Air Ambulance Providers WMAS Other Total Total Number of Harm Incidents Total Number of No/ Harm Near Misses

32 Themes The most frequently reported themes relate to access, admission and transfer delays, patient accidents and missing unavailable clinical equipment are also cited as primary issues. The most frequent reported harm incidents relate to ambulance delays, patient falls and other injuries whilst transferring/ transporting. Medication Errors During 2014/15 no medication errors were reported that resulted in an SUI or patient harm. Following several reports (Francis, CQC, MHRA etc.) which indicated that patient harm could result if staff were not open and honest in reporting issues, the medicines team have put into place (in conjunction with staff side) an anonymous medicines reporting system. This system whilst in its infancy is working well with staff reporting medicine incidents anomalously at the rate of an average of three per month. The amount of morphine administered by WMAS paramedics has increased by approximately 15% (this is as a result of allowing staff to administer morphine I.M in addition to I.V; together with an improvement in managing patient s pain) however the loss and breakage rate has reduced by 7%. All medicine incidents reported (from all sources) are reviewed to establish trends, causation etc. and as a result of this information the following change have been made; Ampoule holders are being replaced with a more robust design which are square and not round, this will reduce breakages if dropped and stop the holders rolling off surfaces. The procedure for restocking Controlled Drugs at CAS sites drugs has been alerted to reduce crews down time. The security of all Categories of Drugs has been improved by reviewing and amending storage arrangements at all locations. Locality managers carryout Controlled Drug audits weekly, this is in addition to the medicines team carrying out random Controlled Drugs audits. Infection Prevention and Control Each quarter across the region for hand hygiene, cannulation, vehicle and premises cleanliness. The hand Hygiene audits are split between at hospital observations and at the point of care observations by Clinical Team Mentors (CTMs) with a minimum of 1,000 observations done each year. Cannula insertion observations are also done by CTMs with a minimum of 400 done each year. The results (below) have shown a consistent rise in compliance year on year. 32

33 Premises and vehicle cleanliness audits are completed by the Area Teams every quarter, with verification audits completed by the IP&C team. Any variations in audit scores are investigated, then actions take place to rectify any issues found. In 2014/15 one challenge faced was to ensure all staff were aware of procedures to follow if any suspected cases of Ebola were identified in the West Midlands. Processes, kit and information were produced in conjunction with the Emergency Planning department to ensure all staff and the population of the West Midlands would be kept safe if we were to have any cases in this area. Safeguarding Safeguarding for Adults and Children is embedded in WMAS throughout Policies and Procedures and literature. All staff within WMAS are encouraged to report safeguarding concerns to the single point of access Safeguarding Referral Line. Adult YTD Children YTD Referrals Referrals , , % variance 32% % variance 24% Engagement with the 27 Safeguarding Boards across the West Midlands continues to grow and develop. With the Care Act 2014 WMAS is developing and aligning processes and guidance for all staff. Referrals are monitored on a monthly basis as a way of demonstrating effective engagement and awareness of staff of such issues. Domestic Abuse Reporting In April 2014 WMAS introduced Domestic Violence in the mandatory training program. This included referring domestic violence and informing the Police. Key engagement with all Police Force Domestic Leads were developed across the West Midlands 33

34 Serious Incidents Serious Incidents (SIs) include any event which causes severe harm or death; a scenario that prevents or threatens to prevent a provider organisation s ability to continue to deliver healthcare services; Allegations of abuse; adverse media coverage or public concern about the organisation or the wider NHS. A total of 25 serious incidents have been reported by WMASFT over this reporting period. All serious incidents are investigated using Root Cause Analysis methodology to determine failures in systems and processes. This methodology is used to steer away from blaming operational staff at the sharp end of the error, to ensure the organisation as a whole learns from mistakes and that systems are reinforced to create a robustness that prevents future reoccurrence. Following investigations into serious incidents, it has been highlighted that the Trust needs to improve; Access to equipment to enable crews to practice skills where their exposure to real life situations is minimal Improve local awareness in relation to management of posterior stroke Agree a systematic approach for prioritising category green 2 calls National Framework for Reporting and Learning from Serious Incidents Requiring Investigation Total number of SI's by Division Birmingham C&W Staffs EOC Commercial Services Black Country West Mercia Patient Transport Services Air Ambulance Other

35 NHS 111 Since WMAS stepped in to run the NHS 111 service in the West Midlands in November 2013, the Trust has received over 1.25m calls. In doing so, we continue to perform above target of answering at least 95% of calls within 60 seconds. As public confidence continues to be restored in the service, call levels have continued to rise with more than 940,000 coming into the service in the previous 12 months alone. The demand on the local health care economy has been well documented in recent months, which makes the work we are doing in our call centre more essential than ever. The Trust works closely with local emergency departments and the 999 service to try and relieve some of the pressure on the healthcare system with more enhanced clinical intervention. Born out of that desire, the Ambulance Liaison Desk has been created to clinically screen Green 2 ambulance endpoints. Similarly, the Clinical Intervention Desk screens emergency department outcomes. 111 has been able to clinically screen up to 70% of all Green two end points and up to 80% of all Emergency Department endpoints therefore making significant reductions in the number of patients sent to Emergency Departments across the region. Christmas proved to be the busiest time for the service when the Trust received 50% more calls compared to same time in This was highlighted by the two days the Trust has experienced when a total of 15,880 calls were received across December 26 (7263) and December 27 (8617). Despite the continuous busy nature of the service, WMAS has been the best weekly performing 111 provider on many occasions, including successive weeks at the end of January and start of February. As the number of people using 111 continues to rise, the Trust is keen to enhance the service for patients and attempts to ease the pressure on the wider healthcare economy at the same time. As a result, dental nurses have been introduced into the call centre together with the Trust taking part in a number of innovative pilots. These include: GP early intervention. The use of pharmacist and pharmacy endpoints. Installing a mental health nurse within the 111 call centre. GP in-hours booking. A 111 online service. In order to learn through patient feedback, the Trust developed a 111 patient survey which as well as being posted out to users of the service, will be available to all on the new WMAS website. The results from the surveys returned across the last six months have been encouraging with almost 94% of patients saying they were very satisfied or satisfied with the service they received whilst just over 94% said they were extremely likely, or likely, to recommend the service to others. 35

36 If any patients raise concerns in their responses, we respond to them to allow us to investigate the concern, feedback to the patient and address any issues we find. The Trust is currently in the middle of the tender process to win the new NHS 111 West Midlands contract which will last for five years. We have put a great deal of hard work into developing the service during the last 18 months and hope to continue to be able to do so when the contract is awarded in May Patient Safety and Experience Incidents, Complaints, Concerns and Compliments PS Incidents Complaints PALS Compliments There is an overall satisfaction with the service. Often specific staff are identified as being particularly helpful. Patients report being happy with assessment and advice provided. We also receive praise relating to referral to other services. PALS and Formal Complaints Key themes for PALS and formal complaints relate to Unhappy with other Health Care Provider - is a large section of our complaints and refers mainly to complaints about the OOH Service, other services like A&E or own GP Surgery. WMAS Paramedics are included in this section. All complaints are logged for the different services and passed to the service for investigation and direct response to the complainant we don t get involved any further. Staff Attitude and Engagement - as it suggests, refers to concerns with communication skills like not listening, tone of voice, talking over patients, lack of empathy etc. Where the complaint is upheld the individuals receive further support from Line managers who look specifically at improving customer care skills. We also monitor via random call audit to see if learning has been put into place. 36

37 Complaints and Contacts Complaints The Trust has received to date (1 Apr 28 Feb) in 2014/ complaints compared to 377 in 2013/14, a decrease of 6.4% (24). The main reason for a complaint being raised relates to Response (Delay in the arrival of an Emergency or Non-Emergency vehicle). Breakdown of Complaints by Service Type YTD: Variance 13/14-14/15 EOC % EU % PTS % OOH 0 0 Other % Total % Justified Complaints The table below indicates that of the 237 closed complaints, 157 were classed as justified or part justified. If a complaint is justified, learning will be noted and actioned locally and will also be fed into the Learning Review Group for regional learning to be identified and taken forward. Total Justified Non Justified Part Justified Call Management Attitude and Conduct Clinical Driving and Sirens Response Other Total PALS Concerns have increased year on year with 1075 concerns raised in 2014/15 compared to 1051 in 2013/14, an increase of 2.2% (24). The main reason for a concern being raised related to response which includes response emergency ambulance delays and issues with non-emergency patient transport arrangements. Ombudsman Requests The majority of complaints were resolved through Local Resolution and therefore did not proceed to an independent review with the Parliamentary and Health Service Ombudsman. During 2014/15 9 independent reviews were carried out compared to 12 in 2013/14. 4 were closed with no further action, 5 remain under investigation by the Ombudsman. 37

38 Patient Feedback/ Surveys The Trust has received 126 completed surveyss through the t Trust website relating to Emergency Services and 9 relating to the Patient Transport Service. During this year the Patient Experience Team has been attempting to implement and promote the Friends and Family Test (FFT) prior to its official launch on 1 April The FFT should be offered to patients that dial 999, receive an emergency response but are not conveyed to hospital andd patients that use the Non-Emergency Patient Transport Service. Patientt are offered a freepost leaflet to return to regional HQ or they can complete the return on online throughh the Trustt website. To date we have received the following responses: Patient Transport Servicee 15 paper, 2 online Emergency Services 2 paper, 7 online Patient Engagement The Patient Experience Team continues to engage with Renal Patients, with focus meetings being undertakenn at Woodgate Dialysis Unit. The T Teamm objective was to engagee with under 18 year old, with 12 events attended that have included attendance at Young carers, Emergency Services Open days, School visits, Cub visits. Compliments The Trust has received 1121 compliments in 2014/15 compared to 972 in 2013/14. It is pleasing to note that the Trustt has seen an increase of 15.4% (149) in Compliments received. The Trust has a dedicated compliment address: compliments@wmas.nhs.uk which iss available to members of public via the Trust website and PALS leaflets. 62, 743 Hits on the website since December Junior Paramedic packs distributed 38

39 Annex 1: Statement from the Lead Commissioning Group Co-ordinating Commissioner Response This report demonstrates WMAS NHSFT achievement of its visions and values to deliver responsive and quality services to the West Midlands population. The urgent and emergency ambulance service in the West Midlands is commissioned across 22 CCGs, which provides opportunities to deliver both economies of scale and performance at operational quality thresholds level, however, can cause performance challenge at individual CCG level. Most noticeable has been the trusts struggle in the period in their ability to deliver against operational quality performance targets in certain CCG areas and indeed regional outturn on the Red 2 key performance indicator. This has been a result of significant reductions to workforce capacity throughout a period of sustained industrial action during the Autumn and Winter months. During significant work has been undertaken by WMAS and the 22 West Midlands CCGs to identify where benefits can be realised across care pathways to support and shape the local urgent care agenda. Commissioner and provider combined efforts has enabled us to focus on some key areas essential to the future success of the five year forward view. As a result the CQUIN schemes included in the 2015/16 contract period should support innovative change and facilitate changes in service delivery that provides improved access to care closer to home over the coming years The workforce within WMAS now includes a high percentage of highly skilled paramedics, and a variety of vehicle types that provide a response, the paramedic-led clinical care available to patients now reflects the changes in services required to respond to callers of 999, who are predominantly 60% green urgent activity. With only 40% of activity being real emergency and categorised into the Red activity bracket. The CQUINs that have been agreed between WMASFT and Commissioners in 2015/16 will support fast effective conveyance for those patients that require speedy response and transport to hospital. However, it will also better support the higher volume of patients that call with urgent but not emergency care needs, and pathways will be put into place to ensure that appropriate responses are made to those patients, and where that response is a need for social care support, access to mental health services or support from primary care or community services, then this will be made available to patients direct from their contact with the ambulance service. The West Midlands CCGs are committed to working with WMAS in a collaborative and proactive way to deliver mutually beneficial outcomes for patients. The West Midlands CCGs consider this Quality Account to demonstrate a successful set out outcomes for WMAS NHFT, acknowledging the pressures within which the organisation has operated. 39

40 ANNEX 2: STATEMENT FROM THE COUNCIL OF GOVERNORS Chair of Patient Quality Panel on behalf of the Council of Governors This year s report is offset against what has been a very challenging year for the service. As trust governors we have seen first-hand the issues caused by increased demand, winter pressures, hospital reconfiguration and industrial action. What is pleasing to note is the strategic planning and dedication of the workforce, which has helped the service through this difficult period. We do of course recognise improvements are still to be made and are reassured with the current Student Paramedic recruitment programme, decreasing the process from 20 down to 15 weeks and increasing the Paramedic skill base regionally which will have a benefit to patients care. We note that ECA to Tech conversions are yet to take place and would hope this does happen within The Commissioning for Quality and Innovation Performance Indicators each of which were achieved at 100% has led to the service receiving an additional 4 million in funding which highlights the work carried out across the trust to meet these benchmarks. If we are to seek the reassurance of the areas the service covers we wish to see a breakdown of performance by area/jurisdiction as requested by Healthwatch organisations and this information should be provided to them. The Patient Quality Panel will continue to analyse quality data and meet with trust directors and strategic staff to ensure the best possible service is provided proportionally and fairly across the region. 40

41 ANNEX 3: LOCAL HEALTHWATCH AND OVERVIEW & SCRUTINY COMMITTEES Shropshire Health & Adult Social Care Scrutiny Committee Members of Shropshire Council s Health and Adult Social Care Scrutiny Committee commend WMAS on achievement of the priorities identified in last year s Quality Account, and agree with the priorities identified for They believe the Quality Account demonstrates a commitment to continuous, evidence-based quality improvement and identifies where improvements need to be made. Members felt it would be useful for the Quality Account to include comparative data from other Ambulance Services. Members were pleased to find the report accessible and easy to read. The inclusion of a glossary is welcome but it is suggested that this be included at the very beginning of the document rather than at the end. Members acknowledge that the challenge of meeting rural targets will never go away. The efforts of WMAS in providing measures to mitigate this are positive. Members concurred with the prioritisation of patient experience and outcome over targets. Members would like to thank the Trust for its generosity in officer time, information dissemination, and candour in responding to requests from the Committee. They have requested 3 monthly updates on progress on the Key Performance Indicators and progress against the Quality Account priorities The Committee looks forward to continuing working with the Trust to ensure the best possible outcomes for the people of Shropshire. Healthwatch Shropshire Healthwatch Shropshire is pleased to be invited to consider and comment on the Trust s Quality Account review of and forward plan for We welcome the breakdown of Red 1, Red 2 and Red 19 figures for Shropshire, however, we are concerned to note that these are significantly lower than the WMAS performance overall. Based on comments we have received, of specific concern for Shropshire residents is response times in rural areas. It is disappointing that at the time we were invited to consider and comment on the Account, details of achievement against commissioners quality improvement and innovation goals were not available for comment. Similarly, the National Audit table is incomplete and the information on the national and local audits doesn t tell the reader about the impact on patient care and experience. 41

42 In the priorities for we welcome the focus on engagement and patient experience, however, what success will look like for the three priorities needs to be better qualified and more specific, for example what would improved engagement look like for disadvantaged groups (and which groups does this include rural?). In addition, on page 9 we don t know what the clinical performance measurements are and how these are linked to outcomes for patients and response times. A minor failure is stated in compliance with CQC registration: Outcome 4: Care and Welfare of people who use our service. We would like to see this explained and addressed. Review of performance against priorities middle column shows what has been done (output) but the final column how had we done doesn t show what different has been made (outcomes). In addition, some of the activities do not seem to relate to the priority. Where improvements have not been made against priorities, it would be good to understand the reasons why and use the learning going forward. For some priorities it is not clear what the aim is to achieve. When reporting on Ombudsman requests, we are concerned that outcomes of the outstanding cases mentioned in last year s Quality Account do not appear to have been reported upon in this year s Account. We note that you list among your pilots a 111 online service. We hope this utilises the existing NHS Choices website rather than a new website which could potentially cause the public confusion. We noted that demand for WMAS services has increased, so it would be interesting to see that referred to under complaints and contacts as the number of complaints has gone down and the number of PALS concerns have slightly increased. Also, it is positive that learning is noted and actioned when a complaint is upheld, but it would also be good practice to learn from complaints which are not upheld. Healthwatch Shropshire is keen to develop its relationship further with the Trust and we would welcome more of WMAS meetings being held across the area including Shropshire. Worcester Health, Overview & Scrutiny Committee The improved readability of this year's Quality Account is welcomed. However, further commentary and context is needed to give the public a real sense of the main headlines behind the organisation's work this year, and the particular issues experienced in Worcestershire the extreme pressures on emergency services across the health economy and impact on ambulance response times. 42

43 It would be helpful to understand the basis for priorities and how they will be measured, although it is understood that they reflect national targets and that this information will be added once the national priorities are finalised. Divisional reports are welcomed, having been requested by us for several years. HOSC's links with the Ambulance Trust work is assisted by two lead members attending public board meetings. They report being overall impressed with the Trust's work to improve performance targets for ambulance response times, however, the Board's paperwork is very complex and does not present a clear message of its work; greater use of more accessible communication channels, such as video, would be beneficial to the public. The performance gap between rural and urban areas is concerning and whilst acknowledging the greater challenge in rural areas, it is important to improve performance. The reported drops in hospital conveyance rates as a result of more patients being treated at the scene will contribute to increasing demand on Worcestershire's hospitals. The HOSC will be continuing its scrutiny of patient flow over the coming year. Worcestershire has experienced a significant rise in activity (13%), against typical rises of 5-7%, with increased 999 calls a contributing factor. We understand the Trust is working alongside colleagues from the Acute Hospitals' Trust on this matter, and this is something HOSC will also monitor. Healthwatch Telford & Wrekin Healthwatch Telford and Wrekin is pleased to be invited to consider and comment on the Trust s Quality Account We were pleased to read that the number of official complaints has decreased; however, it is disappointing that the number of PALS concerns has increased, it appears that themes around response time are the focus of the issues raised. We acknowledge that the Trust is working towards addressing the issues raised. We are encouraged to see that there is continued focus on patient experience and engagement in the Trust s priorities for It is encouraging that the Trust has a strong commitment and involvement in research studies and audit. We pleased to see the focus on young people has been highlighted in several areas of the report including attending several community events. The report highlighted the improved performance in delivery of the NHS111 service and the innovative ways being piloted to enhance the service for patients, we look forward to hearing the results of the pilots. 43

44 We note that WMAS performance figures have been broken down into areas; and we note the good response times in certain ares of Telford and Wrekin but there continues to be challenges in others, the delivery of the service to our patients in these areas will need to be addressed. We are pleased to acknowledge the Trust commitment to mandatory training on Domestic Abuse and the continued engagement across a multidisciplinary team. We look forward to continuing to develop the working relationship with the Trust and using our patient experience data to contribute to the ongoing improvement in patient care. Telford & Wrekin Health & Adult Care Scrutiny Committee The Telford and Wrekin Council s Health and Adult Care Scrutiny Committee is unable to provide comments on the 2014/15 Quality Account due to the fact that the national timetable for the HOSC to comment on the Quality Account coincides with the pre-election period for the Borough elections and the appointment of the new Scrutiny Committee at Annual Council. Healthwatch Herefordshire Some specific issues which we believe are particularly important are as follows:- The Draft report shows a high degree of engagement and drive to improve patient care, with inter-agency working, evidence-based care improvement, and partnership with academia and medical suppliers. The priorities in Part 2 can be welcomed and supported by Healthwatch Herefordshire, particularly for: - Learning Disability engagement and communications - Stroke Patients - Child and Adult Patient Safeguarding There is a weakness in the description of Workforce and Organisation Development (p22) The target for achieving Paramedic mix of Ambulance staff is given as 70% for the year 2017/18. An achieved figure of 61% is reported for 2013/14. The figure for the year the Quality Account is about (2014/15) is not given! but is presumably less than the 65% target for 2015/16. If the improvement 13/14-14/15 is something less than 5%, it does seem credible to achieve a few more % to reach 65% for 15/16. 44

45 However, the subsequent 5% jump required up to 16/17 seems unlikely to be achievable, particularly in light of the bigger base number involved. This was not evident in Part 3. Part 3 How WMAS did Performance against a priority for last year of focusing on the under-18s (p25) seems very good and something HWH can applaud. P28 Patient Safety, and p31 Serious Incidents, still bury Herefordshire in a group of counties which WMAS refers to as West Mercia (Herefordshire, Shropshire, Worcestershire etc) rendering these figures of no use to us. Reporting at West Mercia level is a relic of WMAS legacy reporting systems and WMAS internal convenience. This practice was changed last year in the monthly performance reports WMAS sends out to Healthwatches and HOSC. There is no technical reason why this could not be applied to all reporting and this Quality Account Report. (P49 and 50 do give a little more detail, but again in the form of very high level wholeyear averages, with huge variations within them, so they don t actually inform much.) P34 Complaints - Actual numbers of complaints mean little unless set against a baseline of numbers of calls dealt with producing, say, complaints per 10,000 calls. Finally, the report does describe WMAS territory as including a very large proportion of rural areas. However, it says virtually nothing about the big variation in performance in places like Herefordshire, and nothing about improving it. Warwickshire County Council s Adult Social Care and Health Overview and Scrutiny Committee, Nuneaton & Bedworth Borough Council, Healthwatch Coventry and Healthwatch Warwickshire It is the belief of this and other QA Task and Finish Groups across Coventry and Warwickshire that the intended audience for this document is the public, and that NHS Trusts have to face the dilemma every year of producing a document that answers a broad range of conflicting demands from different audiences. An added challenge for this Trust is the vast geographical area covered by WMAS and the many different local authorities and Healthwatch organisations included in that area. It is therefore difficult to engage with the Trust to review and identify quality themes and issues that members believe should be both current and future priorities that reflect local priorities. 45

46 We welcome the commitment in the QA to demonstrate how the priorities for 2015/16 have been identified and what success will look like in each case. The priorities are clear and reflect the aims of an ambitious and a learning organisation, but are difficult to translate into different areas with different challenges. Members of the Group were invited to spend time with local ambulance crews and the commitment and professionalism of the staff was commendable. In the single instance where data is divided into different areas, we were concerned at the high rate of Patient Safety Incidents recorded for Coventry and Warwickshire. The Group are committed to their role in monitoring quality assurance at a local level and would welcome more local content in the QA. The following additional comment is included from Healthwatch Warwickshire: Healthwatch Warwickshire (HWW) fully supports the general comments made on behalf of the joint Quality Accounts Task and Finish Group, established to consider the WMAS Quality Accounts from a Coventry and Warwickshire perspective. On behalf of consumers in Warwickshire there is an additional issue to be considered. HWW represents consumers in a County which has significant rural areas and which presents very different challenges to Coventry, for an ambulance service. We were very impressed by our visit to the Coventry Hub in However, there is no information in the Quality Accounts draft that enables us to consider performance in our County. Even in the single instance where data is divided into separate areas we are not able to determine whether the high rate of Patient Safety incidents is an issue that should concern consumers in Warwickshire or Coventry or both. Being openly accountable to relatively small communities must be a significant challenge to a regional Ambulance Trust. An answer will have to be found, if they are to retain the confidence of consumers in these local areas. HWW is committed to working with all relevant parties to resolve this issue and ensure that more informed comment will be possible next year. Staffordshire Health Scrutiny Committee We are directed to consider whether a Trust s Quality Account is representative and gives comprehensive coverage of their services and whether we believe that there are significant omissions of issues of concern. There are some sections of information that the Trust must include and some sections where they can choose what to include, which is expected to be locally determined and produced through engagement with stakeholders. 46

47 We focused on what we might expect to see in the Quality Account, based on the guidance that trusts are given and what we have learned about the Trust s services through health scrutiny activity in the last year. We also considered how clearly the Trust s draft Account explains for a public audience (with evidence and examples) what they are doing well, where improvement is needed and what will be the priorities for the coming year. Our approach has been to review the Trust s draft Account and make comments for them to consider in finalising the publication. Our comments are as follows. Introduction. We support the inclusion of the Trust s Vision, Values, and Strategic Objectives an explanation of what a QA is, why produced and who has been involved in the preparation. We note the statement from the Board summarising their view of the quality of services provided or subcontracted and the Statement of Quality from the Chief Executive and Chairman is to be included. The presence narrative containing and outlining a list of services is acknowledged. Priorities, we note that Account includes details of the Priorities for Improvement, how they were chosen, links to the three domains of Patient safety, Clinical effectiveness Patient experience, how to be achieved and links to reviews and strategy. Progress since the last QA is present with systems to monitor measure and report progress. Statement of Assurance, we note the number of services provided/ subcontracted and reviewed. Detail of income is present but we feel that the document would be enhanced by the inclusion of more detail. We are pleased to note the recognition of the importance and value of participation in local and national clinical audits, subsequent outcomes and lessons learned. The goals agreed with the Commissioners, CQUIN Indicators are present; we note that the financial achievement against indicators is to be included. We are of the view that an e-weblink to further information and the inclusion of more case studies would add value to the document. In relation to the Priorities for Improvements we are pleased to see the level of detail included and the presence of the Work Force and Organisational Development. CQC registration, it is noted that there are no conditions, enforcement action other outstanding reviews or investigations. In relation to hospital episodes, payments by results clinical coding we acknowledge that these do not apply and that information concerning Information Governance and Data Quality is available to the reader. 47

48 Review of quality performance, there is an explanation of how the contents /priorities have been determined who has been involved and the rationale for selection. There is information about specific services and specialities as well as what the patients say about them. In respect of accuracy of Patient Safety data we suggest that it should be revisited before publication. Indicators and evidence including from complaints, patient and staff surveys inspection and benchmarking is present together with performance against key national priorities. Referring to the Stroke care bundle,clinical managers continue improve work in this area by facilitating workshops, auditing cases and correct resources being deployed to stoke patients. We are of the view that the value of the document would be added to with the inclusion of a number of the resultant outcomes. The provision of information within the document to supplement NHS Employers website- staff surveys would assist the reader. Safeguarding, as Safeguarding for Adults and Children is embedded through policies, procedures and literature we suggest that the document would benefit with the inclusion of more factual detail concerning this area. The relationships between the respective CCGs within the Staffordshire Division are clearly integral to the overall effectiveness of the Trust. We recommend more detail of the frequent interaction between parties be advantageous. We are pleased that there is a clear pathway to enable readers to provide feedback or to offer suggestions for the content of future reports. We note that this is a draft document but would expect that evidence and information awaited as indicated throughout will be added to the final document before publication. To conclude considering the purpose and nature of the document, you may consider that the inclusion of a photograph of an ambulance be appropriate. Healthwatch Coventry Healthwatch Coventry is the consumer champion for local health and social care services, working to give local people and users of services a voice in their NHS and care services. Local Healthwatch welcomes its role in producing commentaries on NHS Trusts Quality Accounts. Is the document clearly presented for patients/public? The version of the draft quality account Healthwatch Coventry received to enable us to compose this commentary was not complete; some text was missing from paragraphs etc. 48

49 The intended audience for this document is the public, but NHS Trusts face the dilemma every year of producing a document that answers a broad range of conflicting demands from different audiences and meets a template from the Department of Health. The document would flow better if it began with the report on last year s priorities and then moved on to the priorities for the coming year. It would also benefit from an expanded glossary to include all medical terms and acronyms used. Trust Priorities for An added challenge for this Trust in producing its Quality Account is the large geographical area covered by its services and the many different local authorities and Healthwatch organisations included in that area. The local Quality Account Task Group (of which Healthwatch Coventry is a member) has found it difficult to engage with the Trust to review and identify quality themes and issues that members believe should be both current and future priorities and reflect local priorities. We welcome the commitment in the document to demonstrate how the priorities for 2015/16 have been identified and what success will look like in each case. Some priorities would benefit from further detail (we do not know if this is because we have an early draft of the document). For example: Patient experience priority regarding disadvantaged groups - it would be useful to know which 3 groups are the focus of this work. Regarding patient safety priorities: evidence within the document illustrates that the most frequent theme of harm incidents also covers falls and other injuries whilst patients are transported or transferred. This should be reflected in the priorities. Adding benchmark data to the clinical effectiveness priorities would make it easier to see progress against these. The priorities focus on emergency ambulance services. WMAS provides Coventry patient transport services and the 111 service, so we wonder why these are not reflected. WMAS has taken on a new patient transport contract for service provision across Coventry and Warwickshire from 1 April Therefore, we would expect some priorities around implementation of this service within the Quality Account, especially in the light of quality challenges within the previous service (also provided by WMAS). We would also expect some specific local engagement activity with patient groups e.g. renal patients. 49

50 Involvement of patients and public in setting priorities It isn t clear from the document how patients and the public have influenced the quality priorities. Healthwatch Coventry was not able to attend the event WMAS held regarding its Quality priorities, which came quite late in the quality cycle year. Other performance information We hope that sub-contractors are also subject to robust performance review whilst they are being utilised. The CQUIN information is not particularly clear and would not mean much to a member of the public What staff say: it is not clear what the areas for action are and what actions are being taken by the Trust. Regarding the health and wellbeing of staff the target set for increasing paramedic skill mix is lower than the baseline without explanation. The divisional profiles in the annexes are a useful feature of this quality account document. Last year s priorities Two priorities were not achieved: regarding single limb fractures and pain management and one was partly achieved regarding timely effective care. Therefore, these are being carried over into this year s priorities. There is no explanation of the Patient Safety Incidents data and the Coventry and Warwickshire figures are some of the highest. Safeguarding/domestic abuse reporting: the figures for referrals regarding Adult and Children Safeguarding are 32% and 24% up on the previous year. No explanation is given about the reasons. Domestic Abuse referrals to Police were introduced in April It would be useful to have some figures on referral rates. Complaints data: the figures for upheld complaints don t tally 159: out of 237, but the table shows 157 justified or part justified. Those relating to Responses (the largest category) also do not tally. 50

51 Annex 4 - Statement of Directors Responsibilities The Directors are required under the Health Act 2009 and the National Health (Quality Accounts) Regulations to prepare Quality Accounts forr each financial year. Service Monitor has issued guidance to NHS foundation trust boardss on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements thatt NHS foundation trust boards should put in place too support the t data quality for the preparation of the quality report. In preparing the Quality Report, Directorss have taken steps to satisfy s themselves that: The content of the Quality Report meets the requirements set out in thee NHS Foundation Trust Annual Reporting Manual 2014/15 The content of the Quality Report is not inconsistent with internal and external sources of information including: Board minutes and papers for the period April 2014 to May 2015; Papers relating to Quality reported too the Board over the period April to May 2015 Feedback from commissioners datedd 14th May 2015 Feedback from the governors Feedback from Local Healthwatch organisations dated May The trust s complaints report published under regulation 181 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 4 April 2015 and quarterly reports National patient survey published 8 July 2014 National staff survey published March 2015 The head of internal audit s opinion over the Trust s control environment dated 14/05/ 015 the Quality Report presents a balanced picture of the NHS foundationn trust s performance over the period covered; the performance information reportedd in the Quality Report is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the t Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor s annual reporting guidancee (which incorporates the Quality Accounts regulations) as well as the standardss to support data quality for the preparation of the Quality Report (available The directors confirm to the best of theirr knowledge and belief they havee complied with the above requirements in preparing the Quality Report. By order of the board 27 May 2015 Date Chairman 27 May 2015 Date Chief Executive 51

52 ANNEX 5: EXTERNAL AUDIT LIMITED ASSURANCE REPORT INDEPENDENT AUDITOR'S REPORT TO THE COUNCIL OF GOVERNORS OF WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST ON THE QUALITY REPORT We have been engaged by the Council of Governors of West Midlands Ambulance Service NHS Foundation Trust to perform an independent assurance engagement in respect of West Midlands Ambulance Service NHS Foundation Trust's Quality Report for the year ended 31 March 2015 (the 'Quality Report') and certain performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following two national priority indicators detailed on page 20: Category A call - emergency response within 8 minutes Category A call - ambulance vehicle arrives within 19 minutes We refer to these two national priority indicators collectively as the 'indicators'. Respective responsibilities of the directors and auditors The directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; the Quality Report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports 2014/15 ('the Guidance'); and the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Guidance. We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with: Board minutes for the period April 2014 to April 2015; papers relating to quality reported to the Board over the period April 2014 to April 2015; feedback from Commissioners, dated 28 May 2015; feedback from local Healthwatch organisations, dated May 2015; feedback from Overview and Scrutiny Committees, dated May 2015 ; 52

53 the West Midlands Ambulance Service NHS Foundation Trust's complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 4 April 2015; the 2014 national patient survey, dated 8 July 2014; and the Head of Internal Audit s annual opinion over the trust s control environment, dated 22 May We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the 'documents'). Our responsibilities do not extend to any other information. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. This report, including the conclusion, has been prepared solely for the Council of Governors of West Midlands Ambulance Service NHS Foundation Trust as a body, to assist the Council of Governors in reporting the NHS Foundation Trust's quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2015, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and West Midlands Ambulance Service NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) - 'Assurance Engagements other than Audits or Reviews of Historical Financial Information', issued by the International Auditing and Assurance Standards Board ('ISAE 3000'). Our limited assurance procedures included: evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; reviewing analytical reports produced by the Trust; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report; and reading the documents A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. 53

54 The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual The scope of our assurance work has not included governance over quality or non-mandated indicators, which have been determined locally by West Midlands Ambulance Service NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2015: the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; the Quality Report is not consistent in all material respects with the sources specified in the Guidance; and the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Guidance. KPMG LLP Chartered Accountants Birmingham 29 May

55 ANNEX 6: GLOSSARY OF TERMS Glossary of Terms Abbreviation A&E AED AFA AMI AQI BASICs CCGs CFR CPI CPO CPR CQC CQUIN CSD DCA E&U EMB EOC FAST GP HALO HART HCAI HCRT IGT IM&T IPC JRCALC KPIs MERIT MINAP NED NHSP NICE OOH PALS PDR PRF PTS QIA RIDDOR ROSC RRV SI STEMI VAS WMAS YTD Full Description Accident and Emergency Automated External Defibrillator Ambulance Fleet Assistant Acute Myocardial Infarction Ambulance Quality Indicators British Association of Immediate Care Doctors Clinical Commission Groups Community First Responder Clinical Performance Indicator Community Paramedic Officer Cardio Pulmonary Resuscitation Care Quality Commission Commissioning for Quality and Innovation Clinical Support Desk Double Crewed Ambulance Emergency & Urgent Executive Management Board Emergency Operations Centre Face, Arm, Speech Test General Practitioner Hospital Ambulance Liaison Officer Hazardous Area Response Team Healthcare Acquired Infections Healthcare Referral Team Information Governance Toolkit Information Management and Technology Infection Prevention and Control Joint Royal Colleges Ambulance Liaison Committee Key Performance Indicators Medical Emergency Response Incident Team Myocardial Infarction Audit Project Non-Executive Director National Health Service Pathways National Institute for Health and Clinical Excellence Out of Hours Patient Advice and Liaison Service Personal Development Review Patient Report Form Patient Transport Service Quality Impact Assessment Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Return of Spontaneous Circulation Rapid Response Vehicle Serious Incident ST Elevation Myocardial Infarction Voluntary Aid Services West Midlands Ambulance Service NHS Foundation Trust Year to Date 55

56 Further Information Further information and action plans on all projects can be obtained by contacting the lead clinician named on the project. Further information on performance for local areas is available as an Information Request from our Freedom of Information Officer via the address below, or telephone Progress reports will be available within the Trust Board papers every three months with the end of year progress being given in the Quality Report to be published in June If you require a copy in another language, or in a format such as large print, Braille or audio tape, please call West Midlands Ambulance Service on or write to: West Midlands Ambulance Service NHS Foundation Trust Ambulance Headquarters Millennium Point Waterfront Business Park Brierley Hill West Midlands DY5 1LX You can also find out more information by visiting our website: If you have any comments, feedback or complaints about the service you have received from the Trust, please contact the Patient Advice and Liaison Service (PALS) in the first instance;

57 Appendix - Divisional Profiles Birminghamm Division This overview is intended to provide relative information for various bodies, in understanding the composition, operational make up, challenges that face the west midlands ambulance service in Birmingham and Solihull. The Birmingham/Solihull population is circa 1.3 million residents in the area, and a large transient population that travels into the city centre and returns in evening on a daily basis. The conurbation stretches across 445 sqkm, and is in the main an urban profile. The Conurbationn has 4 Clinical Commissioning Groups, with whom the ambulance service interact on a frequent basis. The CCGs are Birmingham Cross city, Birmingham South and Central, West Birmingham and Sandwell, Solihull. The ambulance service has strategically located its 2 main ambulance hubs to facilitate both response times easee of supplemental cover, there is also a satellite community Ambulance station at Aston fire station which has a close proximity to the city centre. An ambulance hub is a centre where staff report to centrally, ambulances are prepared, cleaned and repaired, training and education also takes place. From these ambulance hubs, the ambulances are deployed and strategically placed in line with a dynamic operational plan, the plan changes hourly and depicts the changing activity, this plan is based on emergency activity and historical data, and ensures thatt the ambulance resources are best positioned to meet daily patient activity. Thee Trust occupies a varied assortment of properties to support this deployment, ranging from prefabricated building to fixed buildings we also link in with the other emergency servicess and health care provider colleagues in assisting with accommodation where applicable and thatt is conducive to adherence to the operational plan. 57

58 Performance Birmingham has again achieved its national performance targets for 2014/15 which is a fantastic achievement and shows that patients within Birmingham have received an excellent response to those life threatening calls, this is down to the dedication of the staff and management team to ensure that patients get the best possible response. Current Red performance (National Target=75%). Division YTD % Trust YTD Red % YTD 77.5% Red 2 76% YTD 74.3% Red % YTD 96.8% There is a Performance improvement plan in place across the Division and the main Points are; Reduce sickness to 4% to release manpower to A&E. Currently 3.97% YTD Paramedic on every ambulance, increasing ability to treat patients in the community. Reduce Job cycle times on conveyance 99 min and non conveyance 69 min Increase the staffing levels to ensure that the good performance continues. Increase staffing and resource to match the demand profile. Report weekly to an operational board chair by the CEO. Providing RRVs on the busiest postcodes to ensure a timely response. Overview by HUB Erdington Erdington Hub became operational in September The busiest postcode area B23 (Erdington) which is the unfortunately not the best performing post code. Most challenged post code B90 (Solihull area). The post activity is not a stable measure as volume and performance changes continually by week, Current challenges resource into the outlying areas of Birmingham north due to the shift of resources to the city centre. 111 activities during weekdays and at weekends is challenging in volume. Insufficient alternative care pathways in the area resulting in more transports to A&E and subsequent protracted delays in hospital Performance Hollymoor Hollymoor Hub became operational in July The busiest postcode area B31 (Northfield) B29 (Selly Oak) the best performing post code. Most challenged post code is B14 (Maypole). Other challenges increasing job cycle times across the whole of Birmingham conurbation. 111 activities during weekdays and at weekend s impacts on the accident and emergency performance, current Operational performance above national standards at 78.8%. Aston satellite CAS Station Aston replaced the existing site of Henrietta Street and went live on the 21 st May Aston is the only interoperability site working closely with West Midlands Fire. 58

59 Black Country Division This overview is intended to provide relative information for various bodies, in understanding the composition, operational make up, and challenges that face the West Midlands Ambulance Service in the Black Country. The resident population of the Black Country is approximately 1.1 million people and has seen population increases in recent years; there is also a large transient population that travels throughh the area on a daily basis due to a busy road and rail network. The area stretches across approximately 150 sq. miles, and is mainly urbanised with multiple borough. The Black Country operating division has 4 Clinical Commissioning Groups (CCGs), with whom the ambulance service works in partnership with the System Resilience Groups (SRG s) to improve the care provided to our citizens across all Health & Social Care. The CCGs are Dudley, Sandwell and West Birmingham, Walsall and Wolverhampton. The ambulance service is strategically located in three areas where the main ambulance hubs are sited. An ambulance hub is a unit or building where staff report to centrally, ambulances are prepared, cleaned and repaired, and where training and education takes place. From these ambulance hubs, the ambulances are strategically placed in line with a dynamic operational status plan, based on the emergency activity, and ensure that the ambulance resources are best positioned to meet the daily patient demand. Thee Trust occupies a variety of locations across the area as Community Ambulance Stations and standby sites. Many of these sitess are based on existing estates owned by other emergency service providers and this encourages interoperability and good working relationships when attending the same incident. Black Country is also the site of the Trust Headquarters in Brierley Hill (Dudley area) which accommodates one of the two Emergency Operations Centres, where emergency calls are received and triaged. The regions 111 servicee provision is under temporary contract to the Trust and is also located in Brierley Hill. 59

60 Performance Overview by HUB Post code activity is variable on daily basis, however, historical data proves that certain areas are busier than others and the status plan is adapted to meet the demand based on this data. The following is a snapshot of current performance data: Division YTD % Trust YTD Red % Red % Red % Dudley - DY1 (Dudley) is the busiest in volume and best performing area with over 88.4% of calls attended within targets, DY5 (Brierley Hill) is the next busiest and performance is consistently strong in this area. DY8 (Stourbridge) is the next busiest postcode, which is historically challenged. Current performance is challenged achieving year to date at 74.2% Sandwell DY4 (Tipton) lies between Sandwell Borough and is the sixth busiest area in Black Country, performance is this area is currently good. B70 and B71 (West Bromwich) are the next busiest, followed by B66 (Smethwick). Performance is historically strong in all areas, Sandwell covers the border between Black Country and Birmingham. Current performance achieving year to date at 76.8%. Willenhall WV10 (Bushbury), WS2 (Walsall) and WS3 (Bloxwich) are historically the 3 busiest areas of the Black Country and performance has been challenging. The North area has 5 of the 6 busiest post codes in the Black Country. Current performance achieving year to date at 75.6% Walsall and 75.7% Wolverhampton. There is a Performance Improvement Plan in place across the Division and the main points are: Reduce sickness to 4% to release manpower to A&E. Paramedic on every ambulance, increasing ability to treat patients in the community with plans to achieve 70% paramedic skill mix by 2017 Increase staffing and resource to match the demand profile Report weekly to an operational board chair by the CEO In addition to the above the Division is encouraged to use appropriate alternative care pathways through a clinical hub in the 111 call centre, allowing clinician to clinician referral and improving Hospital avoidance for those patients that can be better cared for elsewhere. 60

61 Staffordshire Division This overview is intended to provide relative information for various bodies, in understanding the composition, operational make up, challenges that face the west midlands ambulance service in Staffordshire. The Staffordshire population is 1.1 million resident in the county, and a large transient population that travels through the county on a daily basis. The county stretches across 1,050 sq miles, and has a mixture of rural and Urban Communities. The County has six Clinical Commissioning Groups, with whom the ambulance service interact on a frequent basis. The CCGs are North Staffordshire, Stoke on Trent, Stafford and Surrounds, Cannock Chase, East Staffordshire, South East Staffordshire and Seisdon Pennisula. This is further grouped into 2 System Resilience Groups (SRG S), North Staffordshire and Stafford being one and South East and East Staffordshire being the other. The formation of the University Hospital of North Midlands (the amalgamation of Royal Stoke and County) is part of the current reconfiguration of services taking place in the county which continues to offer challenges to WMAS. The ambulance service is strategically located in three areas where the main ambulance hubs are sited. An ambulance hub is a centre where staff report to centrally, ambulances are prepared, cleaned and repaired, and where training and education takes place. From the ambulance hubs, the ambulances are strategically deployed in line with a dynamic operational plan that changes each hour, this plan is based on emergency activity, and ensures that the ambulance resources are best positioned to meet the daily patient activity. Thee Trust occupy a varied assortment of properties to support this deployment rangingg from prefabricated buildings to fixed buildings and do link in with our sister emergency services colleagues in assisting with accommodation where applicable to the operational plan. Staffordshire is also the site of one of the two Emergency Operations Centres, where emergency calls are received and triaged. 61

62 Performance Overview by HUB Post code activity is a variable each week and is dependent on the activity in that post code area. A snapshot is provided in this briefing which indicates that instability. Division YTD % Trust YTD Red % Red % Red % Tollgate (Stafford) busiest postcode area WS11 (Cannock) which is the best performing post code also. Most challenged post code ST15 (Stone north) and WS15 (Rugeley). The post code activity is not a stable measure as volume and performance change continually by week, Current challenges include the overnight closure of Stafford hospital, this creates some deficit in performance, 111 activity at weekends challenging in volume, and reconfiguration of Services at the County Hospital. The reconfiguration work consists of the movement of key specialities to either the University of Royal Stoke, or Royal Wolverhampton which as an effect on ambulance movements in the prehospital arena. There is insufficient alternative care pathways in the area resulting in more transports to A&E Current Red 2 performance YTD figure is 70.35% which is below the national Target of 75%. Stoke - busiest postcode area ST5 (Newcastle), ST6 (Tunstall/Burslem) the best performing post code also. Most challenged post code ST7 (Kidsgrove/Audley). Current challenges in this area are the EMS operating level at Royal Stoke University Hospital remains high which creates issues with handovers, support to the Health Economy as a whole to assist with performance in moving patients to alternative pathways, increased 111 activity at weekends impacts on the accident and emergency. Future developments- alternative sites have been sort to relocate the main Stoke hub. Current Red 2 performance YTD figure is 74.7% which is below the national Target of 75%. Lichfield - busiest postcode area B77 (Tamworth), DE14 (Burton) the best performing post code also. Most challenged post code DE13 (Tutbury). Other challenges the sesidon peninsula is covered by Black County Ambulance crews rather than Staffordshire so different dynamics. Majority of the hospitals positioned outside of the Staffordshire Boundary; Reconfiguration of the Stroke pathway in East Staffordshire will see a proportion of patients being taken to Derby if not all Stroke patients from this catchment area being taken to Derby. Current Red 2 performance YTD figure is 68.7% which is below the national Target of 75%. A Performance improvement plan is in place across the Division - Summary of main points Reduce sickness to 4% to release manpower to A&E Paramedic on every ambulance, increasing ability to treat patients in the community Reduce Job cycle times from current levels of 97 minutes to 80 minutes Increase resources into South Staffordshire by demonstrating activity increase Review the daily resourcing plan, and relocate response posts where applicable 62

63 West Mercia Division This overview is intended to provide relative information for various bodies, in understanding the composition, operational make up, challenges that face the Trust in the West Mercia Division. West Mercia Division covers the counties of: Herefordshire Worcestershire Shropshire (Telford & Wrekin and Shropshire County) The population of West Mercia is in excess of 1.1 million and stretches across 2,868 square miles with a combination of both rural and urban communities. This area accounts for more than 50% of the geographical size of the Trust. West Mercia has six Clinical Commissioning Groups (CCG s), with whom the Ambulance Service interact with on a frequent basis. The CCGs are Shropshire, Telford and Wrekin, Herefordshire, South Worcestershire, Redditch and Bromsgrove and the Wyre Forest. There are 5 ambulance hubs which are supplemented by Community Posts. An ambulance hub is a location where staff report to centrally, ambulances are prepared, cleaned and repaired, and where training and education takes place. From these ambulance hubs, the ambulances are strategically placed in line with a dynamic operational plan that changes each hour. This plan is based on emergency activity and ensures that the ambulance resources are best positioned to meet the daily patient activity. The Trust occupy a varied assortmentt of properties to support this deployment ranging from prefabricated building to fixed buildings, and we do link in with our sister emergency services colleagues in assisting with accommodation where applicable to the operational plan. Many of thesee premises are occupied by Community Paramedics in Rapid Response Vehicles. Performance Post code activity is variable each week and is dependent on the activity in that post code area. A snapshot is provided in this briefing which relates to the performance of each County for the financial year-to-date. Many areas of West Mercia present challenges due to the geographical spread of communities and maximising alternative community strategies to provide prompt response to patients are utilised. Red R 1 Red R 2 Red R 19 Hub YTD % Trust YTD 77.5% 74.3% 96.8% 63

64 Worcestershire There has been a 13% increase in activity in Worcestershire this financial year compared to last year. The top three busiest postcode areas within Worcestershire are B98 (Redditch), WR11 (Evesham) and WR14 (Malvern). The best performing postcode area within Worcestershire is WR1 (Worcester). The most challenged postcode areas within Worcestershire are DY10 (Wyre Forest), WR9 (Droitwich) and WR10 (Pershore). Performance in Worcestershire for the financial year-to-date is: Red1-75%, Red2-75.5%, Red %. Herefordshire There has been no change in the level of activity in Herefordshire this financial year compared to last year. The top three busiest postcode areas within Herefordshire are HR1 (central Hereford), HR2 (south west of Hereford city centre) and HR4 (north west of Hereford city centre). The best performing postcode area within Herefordshire is HR1 (central Hereford). The most challenged postcode areas within Herefordshire are HR9 (Ross) and HR6 (Leominster). Performance for Herefordshire for the financial year-to-date is: Red1-69.9%, Red2-73.6%, Red19-92%. Shropshire There has been a 1.5% increase in the level of activity in Shropshire County and a 1.2% increase in Telford & Wrekin this financial year compared to last year. The top three busiest postcode areas within the county as a whole are TF1 (North West of Telford town centre), TF2 (North East of Telford town centre), SY3 (North West Shrewsbury). The best performing postcode area within Telford & Wrekin in TF1 (North West of Telford town centre), in Shropshire County it is SY3 (North West Shrewsbury). The most challenged postcode areas within the county as a whole are SY11 (Oswestry), SY4 (North of Shrewsbury) and TF7 (South of Telford town centre). Performance for Telford & Wrekin for the financial year-to-date is: Red1-75.1%, Red2-77.9%, Red19-98%. Performance for Shropshire County for the financial year-to-date is: Red1-61.3%, Red2-64.4, Red %. A Performance improvement plan is in place across the Division Summary of main points Every effort is made by local operational management teams to constantly improve performance in order for patients to receive the most timely response and clinical care. This includes aiming to achieve: A reduction in sickness to 4% to maximise available resources 64

65 Providing a Paramedic on every ambulance, increasing ability to treat patients in the community Current rosters are designed to have a Paramedic on every vehicle. This will also reduce the number of resources being sent to incidents, keeping them available for other calls Reducing Job cycle times Recruit to achieve the budgetary establishment of requirement staff for the area of 563 whole time equivalent Operational staff (Paramedics and Technicians) Recruiting Community Responders to challenged areas Encouraging Defibrillation sites both within the Community and at sites of high population and public concentration Report weekly to an operational board chair by the Chief Executive Officer Recruitment: Since April 2014, the Trust has recruited an additional 22 frontline staff in Shropshire, 30 in Worcestershire and 8 in Herefordshire. 65

66 Arden Division Introduction This overview is intended to provide information to support the understanding of the composition and operational challenges that face the West Midlands Ambulance Service in Arden. Arden consists of a population of 845,000 residents in the county with a large transient population that travels through the county on a daily basis. The county has a mixture of both rural and urban communities. The population is continuing to expand in Rugby, Nuneaton and Warwick as examples with new housing estates being built. The County has three Clinical Commissioning Groups (CCGs), with whom the ambulance service interact on a frequent basis. These are: 1. Coventry & Rugby CCG 2. South Warwickshire CCG 3. Warwickshire North CCG The Arden Division Emergency & Urgent ambulance provision is located at two hubs/buildings, one in Coventry and the second in Warwick. An ambulance hub is a centre where staff report to at the start of their shift, where ambulances are prepared, cleaned and epaired (fleet on site) by the make ready team and where training and education takes place. Ambulances are mobilised from these hubs to response posts situated at strategic points throughout the Arden County. The Make Ready team ensuree that all operational vehicles are fully equipped and cleaned, ready for the start of each shift to provide the correct environment for patient care. Ambulances are moved on a dynamic basis and in line with our System Status Management operational plan that changes each hour. This plan is based on emergency activity, and ensures that the ambulance resources are best positioned to meet the daily patient activity. 66